Excellent Health Plan Member Name: Veronica Casto Member ID:…
Excellent Health Plan Member Name: Veronica Casto Member ID: MKJ538721P Prescription Group No: W32187 RX Group: 321543 Generic RX $15 Preferred Name brand RX $50 Nonpreferred Name brand RX $70 Unknown State University Prime Care Excellence – HMO Date Issued 04/01/XXXX In-Network Member Responsibility Primary $25.00 Specialist $50.00 PT/OT/SP $35.00 BH, SU $100.00 Urgent Care $50.00 ED $150.00 Veronica had bronchitis for the past eight days. Feeling miserable, she went to the local hospital’s Emergency Department for care. She received a prescription for antibiotics. What co-payment should the hospital collect?